Going to the dentist is a visit that may not be very pleasant and that can cause great fear in some patients due to the pain or discomfort that may arise from undergoing a treatment such as treating a cavity. This has made it popular in recent years to sedate patients who are more afraid or who are going to undergo long treatmentsbut this has left very bad news in the last week.
The case. The focus on sedation procedures has been placed in the focus of public opinion after learning the death of a six-year-old girl after dental treatment with intravenous sedation in a clinic in Alzira (Valencia), and the admission to the ICU of another one who was treated at the same dental center.
These two tragic events, which are currently being investigated, have raised many doubts about this procedure, how common it is and, above all, how it is regulated in our country.
Because logically it is something really shocking to go get a tooth filled or have a root canal and not survive the procedure, when a priori it seems like something completely safe. Although there is one detail that sometimes we completely miss: anesthesia (even if it is sedation) is not nonsense and has very important risks that not everyone can control.
Sedation in dentistry. To understand this situation, you must know that in dentistry there are different levels of anesthesia depending on the procedure to be used. The most common is undoubtedly the one in which an anesthetic medication is pricked into the gum itself (something that hurts quite a bit) to be able to do a filling or an extraction. A local anesthesia that disappears after two hours and does not last longer and that the dentist himself can apply after interviewing the patient and asking about his or her allergies.
But beyond this ‘normality’ we have other treatments for patients who fear being in that situation or who are going to undergo annoying and long procedures. Here you bet on a ‘conscious sedation‘. In this case the patient maintains protective reflexes and the ability to respond to commands such as opening your mouthbut remains completely relaxed
The problem is that the border between “conscious” sedation and deep sedation (where this type of reflex is lost) is quite blurred, especially when powerful intravenous drugs are used in the pediatric population. Precisely for this reason scientific societies They have been demanding for years that these techniques be regulated and are executed only with specifically trained personnel and in environments prepared to respond to an emergency in seconds.
Because in part, the safety of anesthesia It is thanks to the professionals who administer it daily, controlling all the patient’s parameters and having a lot of experience behind them with these drugs. Because a drug of this style seems harmless, but the reality is that there are many emergencies that can arise from the use of anesthetics, such as the great feared malignant hyperthermia.
The regulations. Procedures of this style They have regulation which right now is fragmented. That is, there is no state standard that applies to all clinics in the country, but rather it depends on each autonomous community through its authorization decrees. Even so, different common elements are repeated in the regulations that are:
- Specific authorization to administer intravenous sedation or advanced anesthesia techniques. In the case of Alzira, that authorization did not exist. Something that also raises questions about how he could access these drugs without authorization to do so.
- Existence of a doctor responsible for sedation who may be an anesthetist or a dentist specialized in these techniques. But the important thing is that it is a different person than the one doing the treatment so that they can monitor the patient.
- Specific training in sedation, airway management and also accreditation in cardiopulmonary resuscitation techniques.
- Patient monitoring: the clinic box must have at least monitoring of constants such as blood pressure, heart rate or oxygen saturation. But you must also have the appropriate equipment to deal with an emergency in the middle of the intervention.
In Catalonia, for example, the Official Col·legi d’Odontòlegs i Stomatòlegs maintains a specific registry for clinics authorized to perform sedation, with personnel, equipment and audit requirements. Other communities, such as Madrid or the Valencian Community, include the demands in orders of technical-sanitary requirements for health centers and in their catalog of authorizable activities.
What a mistake. The information that has emerged from Alzira’s case illustrates well the clash between real practice and what the regulations require. The Ministry’s reports now indicate that the dental clinic was authorized as a dental center, but not to perform sedation on patientsdespite the fact that he administered drugs this way to a six-year-old girl at the hands of an anesthetist who also is being investigated. Now it is something that is in the hands of justice that also contemplates the possibility of poor condition of the medication used to sedate patients.
After the death of the minor, doubts have arisen from associations of anesthetists warning of the “serious risk” of perform sedation outside the hospital setting or without specifically trained personnel, and remembering that even “conscious” sedation can quickly evolve into life-threatening respiratory depression. The combination of younger age, intravenous route and an environment possibly not prepared to the level required by best practices constitutes a high-risk scenario that the regulatory framework precisely aims to avoid.
A regulation with obstacles. Although many communities have been fine-tuning their regulations, several legal and technical reviews highlight that the regulation of sedation in dentistry in Spain remains scatteredunequal between territories and, in some cases, ambiguous regarding who can do what and under what conditions.
In some autonomies, complex sedation and general anesthesia are regulated in detail, but “conscious” sedation in consultation, especially when they switch to intravenous medications and benzodiazepines, remains in an area where interpretation weighs more than a unified framework.
What should we look at? With this unfortunate case, logically when we hear about sedation in the dental clinic we can start to tremble. But the reality is that if applied correctly and with the right professional, good dental treatment is achieved without suffering the process of discomfort and possible pain.
That is why before opting for this sedation it is important to ask if you have authorization to carry out this process, in addition to requiring that a professional in these drugs administer the sedation. It is also reasonable to ask for an explanation of what type of sedation will be used, what monitoring will be used, and the procedure in case something goes wrong.
Images | Caroline L.M.
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